Electronic Health Records
and Return on Investment
By Reed D. Gelzer, MD, MPH, CHCC
An oft-heard requirement from an EHR customer is a positive
return on investment. The most important requirement for ROI may seem
self-evident. That is, first and foremost, the implementation itself as to
proceed to completion.
Successful implementations are
characterized by planning and leadership. Planning includes identifying needs
and targeting well-identified business and clinical requirements; then using
these new technologies as tools, not as end-points in themselves. A business
analysis will help identify what an organization can reasonably expect to gain
in resources and care improvement by solving specific issues and meeting
specific needs. If an organization implements any system without a clear set of
objectives and reasons, it should be no surprise that the system may not solve
each and every (unmeasured) problem.
Second, a nearly entirely ignored concept of ROI
calculations with EHRs is risk. The focus is on impacts on revenues and
expenses. However, the million-pound gorilla is the unknown risk factors with
EHRs. For example, at a very basic level of functionality, very few current EHRs
were designed with close attention to fundamental rules for medical records and,
in some cases, cannot meet the well-established requirements for medical records
plus those for business records on computers. Therefore, some EHR systems cannot
produce a legitimate bona fide medical record. For example, many EHRs can
demonstrate that an encounter was altered after signature but cannot distinguish
between the repair of a simple spelling error from a re-writing of an entire
section of a document. Some EHRs have no documentation audit functions at all.
For a good summary of the fundamentals, see the publicly
available AHIMA Practice Brief "Maintaining a Legally Sound Health Record" (http://library.ahima.org/xpedio/groups/public/documents/ahima/pub_bok1_014041.html)
In the course of recent working groups on the Legal EHR,
within HL7 and AHIMA, repeatedly discussants noted that medical records/HIM
staff were not included in EHR evaluation or implementation planning. They were
only brought to the table after critical documentation anomalies were
discovered. In these settings the risks can be incalculable if your particular
EHR system cannot support, for example, routine medical records auditing and
basic business rules of medical records documentation. Some older EHRs can only
generate audit reports performed by the vendor (expensive, possible security
problems). What is the risk of an EHR that generates information that cannot be
verified or can only be verified by expensive time-and-materials reports?
In short, when considering EHR topics, first know your
organization's needs and priorities and, if you cannot justify the business
case, wait until you can. If you must move ahead or have moved ahead, make sure
your EHR system (the software, all support systems and functions whether on
computer and on paper) can support the basic requirements of serving as your
organization's legal health record.
Current standards efforts being vigorously encouraged by
the government will help improve the situation over time but, currently, it is
the “Wild West” out there in the EHR market. Caveat emptor is not a strong
enough phrase to convey the risk of implementing an EHR that cannot serve as a
bona fide medical record. Vendors, when asked why they have not designed their
systems to meet medical records requirements commonly answer, "nobody has asked
us for that yet..." So please do ask.
Current drafts are pending from HL7's Working Group on
functional requirements for the Legal EHR. The Journal of the American Health
Information Management Association published the results of its working groups
on the Legal EHR as Practice Briefs in the Journal of AHIMA issues for
September, October, and November-December 2005 and are available on line through
the FORE section of their website. The Certification Commission for Health
Information Technology (CCHIT) appears to be trying to walk a tightrope between
having reasonable standards and having standards that can be met by vendors with
widely deployed legacy systems.
The EHR discussion is unique in our society in that each
and every one of us stands to benefit enormously from these new tools and
technologies and our communities are depending on us to make good choices in
these times of rapid change. Many authorities appear to be carried away by
enthusiasms and hopes for the "silver bullet solution". Like so many, the EHR
evolution will be more difficult than it appears and careful needs assessment,
planning, leadership, execution and evaluation will still be the mainstays of
successful change.
Reed D. Gelzer, MD, MPH, CHCC
Copyright 2005 Advocates
for Documentation Integrity and Compliance, LLC.
Reprints by permission
For More Information Contact:
Advocates for Documentation Integrity and Compliance
500 Beach Street, Revere, Massachusetts 02151
Tel: 781-289-0629
FAX:
Internet:
info@docintegrity.com
